Hemorrhagic Shock Management in the ED Guidelines

Updated: Mar 22, 2022
  • Author: William P Bozeman, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Guidelines

Guidelines Summary

The fourth edition of the guideline on management of major bleeding and coagulopathy following trauma, by the pan-European Multidisciplinary Task Force for Advanced Bleeding Care in Trauma, includes the following [6] :

  • Early imaging (ultrasonography or contrast-enhanced CT) should be used for detection of free fluid in patients with suspected torso trauma.

  • CT assessment should be provided for hemodynamically stable patients.

  • Low initial Hb should be considered an indicator for severe bleeding associated with coagulopathy.

  • Repeated Hb measurements should be used as a laboratory marker for bleeding, as an initial Hb value in the normal range may mask bleeding.

  • Serum lactate and/or base deficit measurements are sensitive tests to estimate and monitor the extent of bleeding and shock.

  • Repeated monitoring of coagulation, using a traditional laboratory determination (prothrombin time [PT], activated partial thromboplastin time [APTT], platelet counts, and fibrinogen) and/or a viscoelastic method, should be provided.

  • Target systolic blood pressure is 80-90 mm Hg until major bleeding has been stopped in the initial phase following trauma without brain injury.

  • In patients with severe traumatic brain injury (TBI) (GCS ≤8), mean arterial pressure ≥80 mm Hg should be maintained.

  • Fluid therapy using isotonic crystalloid solutions should be initiated in the hypotensive patient with bleeding trauma.

  • Excessive use of 0.9 % NaCl solution should be avoided.

  • Hypotonic solutions such as lactated Ringer’s solution should be avoided in patients with severe head trauma.

  • Use of colloids should be restricted due to adverse effects on hemostasis.

  • Target Hb is 7-9 g/dL.

  • In initial management of patients with expected massive haemorrhage, one of the following strategies should be used: Plasma (FFP or pathogen-inactivated plasma) should be provided at a plasma-to-RBC ratio of at least 1:2 as needed, with fibrinogen concentrate and RBC according to Hb level.

  • Tranexamic acid should be administered as early as possible to the trauma patient who is bleeding or is at risk of significant hemorrhage, at a loading dose of 1 g infused over 10 minutes, followed by an IV infusion of 1 g over 8 hours.

  • Tranexamic acid should be administered to the bleeding patient with trauma within 3 hours after injury.

  • Protocols for treatment of bleeding patients should consider administration of the first dose of tranexamic acid en route to the hospital.

  • If a plasma-based coagulation resuscitation strategy is used, plasma (FFP or pathogen-inactivated plasma) should be administered to maintain PT and APTT < 1.5 times normal control values.

  • Plasma transfusion should be avoided in patients without substantial bleeding.

  • If a concentrate-based strategy is used, treatment with fibrinogen concentrate or cryoprecipitate should be provided if significant bleeding is accompanied by viscoelastic signs of a functional fibrinogen deficit or a plasma fibrinogen level less than 1.5-2.0 g/L.

  • Initial fibrinogen supplementation of 3-4 g is used, which is equivalent to 15-20 single donor units of cryoprecipitate or 3-4 g of fibrinogen concentrate. Repeat doses must be guided by viscoelastic monitoring and laboratory assessment of fibrinogen levels.

  • Platelets should be administered to maintain a platelet count above 50 × 109/L.

  • Platelet count above 100 × 109/L should be maintained in patients with ongoing bleeding and/or TBI.

  • Initial dose is 4-8 single platelet units or 1 apheresis pack.